Utah Telehealth Study – Summary Report Prepared by …utah.gov/pmn/files/109907.pdf · follows that adopted by the World Medical ... is expanding into ... Utah Telehealth Study

Utah Telehealth Study – Summary Report Prepared by Pilot Healthcare Strategies for the Utah Division of Occupational and Professional Licensing June 24, 2014

As specified in the Request for Proposals (RFP) for this study, its objective is to provide greater understanding of telehealth services provided by licensed health care professionals in practice and law. The goal is to help inform public policymaking relative to the public safety, healthcare enhancement and economic implications of telehealth. This phase of the project presents an overview of the findings derived from the four project report sections as well as an analytical discussion of the findings as requested in the RFP. The four report sections of the study and their respective areas of focus are:

1. Major trends, drivers and data points relative to the adoption of telehealth services with

focus on public safety considerations and economic impacts;

2. State law and regulations governing the administration of telehealth services delivered

by licensed health care professionals;

3. Federal law and regulations governing telehealth services delivered by health care

professionals including federal Medicare/Medicaid provider reimbursement policy and

federal guidance on telehealth services delivered by licensed health care professionals;

4. Policy positions of national stakeholder groups with an interest in telehealth services

delivered by licensed health care professionals.

For the purposes of this project, the term “telehealth” broadly encompasses diagnosing,

treating and monitoring patients remotely (versus co-located with a provider) using information


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and communications technology (ICT), also referred to as “telemedicine.” This definition closely

follows that adopted by the World Medical Association in 2009, defining telehealth as the use

of information and communications technology to deliver health and healthcare services and

information over large and small distances.

There are three basic categories of patient information communicated in the practice of

telehealth by licensed health care providers:

1. Interactive, real time, two-way communications between patient and provider;

2. Store and forward: patient data shared between patients and providers and in

consultations among providers;

3. Remote monitoring of patient data such as by intensivists of critical care patients in a

distant hospital.

There are three primary modes of patient communication with providers:

1. Connection to remote provider from an institutional setting such as a clinic or hospital;

2. Connection to remote provider from patient’s private home;

3. Connection to remote provider from patient’s mobile device.

Section 1: Major trends, drivers and data points relative to the adoption of

telehealth services

In this phase of the project, a large quantity of mainstream and specialty media, industry

reports and academic journal articles were reviewed and industry experts queried to identify

major trends, drivers and data points relative to the adoption of telehealth services and related

public safety considerations and economic impacts.

As this report was being prepared in the first half of 2014, the activity level in the practice and

policy environment relating to telehealth increased significantly. The overall impression is that

of a topic that is highly fluid and dynamic, characteristic of emerging developments that

undergo a relatively long periods of development and then approach a tipping point or

threshold kicking off a new, heightened phase of development.

The 2000s represented a decade of startup activity setting the stage for the next phase of

telehealth beginning around 2011-12. Around this time, a number of factors began to converge

sparking interest in telehealth including public and private reforms of health care financing and

delivery and population demographics. The baby boomer cohort began moving into its senior

years and boosting demand for ongoing care and monitoring, particularly those with multiple


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chronic medical conditions. The millennial generation of young adults with native digital literacy

expects to be able to conveniently access information and most any service online including

health care.

A development closely related to telehealth practice is the increasing use of electronic health

records (EHRs). The federal Health Information Technology for Economic and Clinical Health Act

(HITECH) of 2009 appropriated more than $20 billion to encourage hospitals and health care

facilities to digitize patient data and make better use of information technology. In 2013, the

National Ambulatory Medical Care Survey (NAMCS) EHR Survey showed that about 78 percent

of office-based physicians used an EHR system, with adoption of basic EHR systems increasing

21 percent between 2012 and 2013.

By various estimates, telehealth practice is poised for rapid growth. The number of worldwide

patients receiving telehealth services is forecast to increase from less than 350,000 in 2013 to

roughly seven million in 2018, according to a report published by IHS Technology. According to

IHS, telehealth will be driven by employers, private insurers and the federal Patient Protection

and Affordable Care Act, which makes doctors and hospitals more accountable by moving

medical care providers away from fee-for-service medicine where they are paid based on

volume of services to reimbursement based on the value of care they provide.

As Internet-based information and communications technology (ICT) became more widely

available in the late 1990s and early 2000s along with the subsequent introduction of Internet-

enabled mobile devices such as smartphones and tablets in the following decade, the level of

practitioner and regulatory interest in telehealth grew along with it. A Harris

Interactive/HealthDay online survey of 2,050 Americans aged 18 and older conducted between

May 22-24, 2013 found more than one-third of respondents said they were "very" or

"extremely" interested in using smartphones or tablets to ask their doctors questions, make

appointments or get medical test results. Similar numbers of respondents were eager to use

mobile phones and tablets for actual health-care services -- such as monitoring blood pressure

or blood sugar, or even getting a diagnosis.

However, since mobile devices have been in widespread use for a relatively short period of time

-- spawning the term mobile health or “mHealth” as a remote form of accessing medical care –

not enough time has passed to assess it. “We really found limited evidence that mHealth in and

of itself has shown its effectiveness,” observes Keith Toussaint, executive director of business

development, Global Health Solutions, at Mayo Clinic.

With the increase in the robustness of Internet connections and free or inexpensive two-way

videoconferencing, remote face to face interactive visits between health care professionals and

http://www.fiercehealthit.com/story/patients-using-telehealth-services-hit-7-million-2018/2014-01-17

http://www.fiercehealthit.com/story/patients-using-telehealth-services-hit-7-million-2018/2014-01-17

http://info.imsresearch.com/lz/Instances/lz/documents/InMedica/Brochures/Abstract%20-%20World%20Market%20for%20Telehealth%202014%20Edition.pdf

http://www.forbes.com/sites/brucejapsen/2013/12/22/obamacare-doctor-shortage-to-spur-2-billion-telehealth-market/


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patients are now more accessible. That enables a wider scope of communication beyond voice

telephone calls and emails. It expands direct patient access to telehealth services without the

need for patients to travel to an institutional setting such as a clinic or hospital to consult with a

health care professional at another location. In that regard, telehealth is another form of

patient empowerment with the potential to transform health care just as webmd.com and

other sources of online medical information that allow patients to access a virtual library of

medical information at their fingertips. Now patients can access both health related

information and health care providers quickly and conveniently. This defines the second – and

current -- generation of telehealth services.

Some veteran practitioners believe the addition of two-way video is the key technological

development setting the stage for the next generation of telehealth growth. Steven J. Davidson,

MD, senior vice president and CMIO at Maimonides Medical Center in Brooklyn, New York,

notes that the addition of interactive video has advanced telehealth practice to the point where

it can eliminate the need for 60 percent of co-located physician-patient interactions.

However, since the adoption of two-way video primarily using a patient’s home Internet

connection rather than via a mobile device outside the home is still relatively new and many

homes lack sufficient landline Internet connectivity to support it, growth could be slow and take

place over the next two to three decades. Brendan Carr, MD, assistant professor of emergency

medicine at the University of Pennsylvania’s Perelman School of Medicine, notes research

shows the lag time between research and integration in the inherently conservative practice of

medicine can take up to 17 years.

Telehealth is emerging as a crucial building block in the delivery of care, according to panelists

at a forum hosted in early 2014 by the Robert Graham Center for Policy Studies in Family

Medicine and Primary Care. The implementation of the Affordable Care Act is leading to

increased demand that physicians interact with more patients, speakers noted, pointing to

telemedicine as a potential solution. This section of the Utah Telehealth Study found telehealth

services are being provided in a variety of settings and delivery modes including primary care,

hospitals and follow up care, emergency services, preventative care and institutions such as

prisons and schools.

Primary care

Telehealth is being practiced in the context of non-urgent primary care by online clinics

including Teladoc, Stat Health Services and American Well that connect patients by phone and

online to doctors licensed in patients’ state of residence. A major impetus for these services is

access and convenience compared to an in-person visit to a doctor’s office or clinic or waiting

for an appointment during normal business hours. Teladoc, which began by offering simple,


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phone-based consults with a doctor, is expanding into online solutions, virtual onsite clinics

(making use of kiosks) and physician-facing portals. In the context of primary care, telehealth

not only bridges distance. It breaks down the longstanding time barrier to access to care since

most primary care providers maintain standard Monday through Friday business hours.

Primary care telehealth services are also being adopted by employers. According to an article

appearing in BloombergBusinessweek in early 2014, hundreds of employers of all sizes are

contracting directly or through their insurers with telehealth providers to cut medical costs and

give workers 24-hour access to doctors and nurse practitioners. Insurer WellPoint partnered

with Boston-based American Well to offer telehealth services to 3.5 million of its health-plan

subscribers last year and intends to extend the service to another 32.5 million over the next 12

to 18 months. UnitedHealth Group began a pilot program in January 2014, providing 310,000

subscribers in Nevada with virtual physician visits.

Consults among providers

One of the more established forms of telehealth is consults among providers. One example

involves a patient with a severe case of scoliosis — an abnormal curvature of his spine. This led

to severe chronic pain, anxiety, depression and sleep apnea. To develop a treatment plan, a

physician assistant remotely presented the case to University of New Mexico experts in

psychiatry, internal medicine, neurology, physical therapy and rehabilitation medicine. The

health care providers took turns asking questions and discussing the patient. Together, they

came up with a course of treatment that resulted in the patient sleeping through the night and

getting his anxiety under control, improving his quality of life.

Emergency services

Telehealth is also being practiced by first responders. At Oregon’s Clackamas Fire District #1,

tablet computers are on every fire engine and responders carry wireless hot spots with them.

District Director Kyle Gorman estimates as many as 30 percent of emergency calls could be

handled with a physician Skyping the patient, avoiding a trip to a hospital emergency room.

Institutions

At the Louisiana Department of Corrections telemedicine enables remote physician

services, clinic scheduling for routine check-ups, emergency consultations and

scheduled visits.

Students at Ossun Elementary School in Lafayette, Louisiana (which operates a

municipal fiber optic telecommunications network) with minor medical issues such as

earaches, sore throats or other common ailments will be seen on the elementary school

campus by a doctor in an exam room about five miles away at Carencro Middle School’s

school-based health center. Using Bluetooth-enabled stethoscopes, otoscopes and


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ophthalmoscopes, a pediatrician will examine patients at the elementary school as part

of a telehealth program partnership between the Lafayette Parish School System and

Lafayette General Health and its foundation. The goal is to test the telehealth model and

explore a more cost-effective way to expand school-based health services across the

district.

Hospital and hospital outpatient care

Telehealth is being employed in hospital and hospital outpatient settings. For example,

intensivists remotely monitor patients in critical care units of distant hospitals. A study found

that the number of U.S. hospitals using telemedicine in ICUs increasing, growing by an annual

average of 8.1 percent from 2010 to 2014.

Chronic disease management and home-based care to avoid hospitalization

In the United Kingdom, more than 100 telehealth projects are running across National

Health Services (NHS) organizations to address patients with chronic conditions such as

congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and

diabetes. According to InMedica, a division of IMS Research, 308,000 patients around

the world were monitored remotely by providers in 2012 for congestive heart failure,

chronic obstructive pulmonary disease, diabetes, hypertension and mental health

conditions.

In Florida, tablet computers are being used to monitor cardiac patients at home

recovering from surgery. Florida’s Memorial Regional's Home Health Services credits the

program for reducing its 30-day hospital readmission rate among cardiac patients to less

than 2 percent — far lower than the 22.8 percent national average and Memorial's

overall 19.9 percent readmission rate.

At the Mid-Appalachia Telehealth Project is in East Tennessee, diabetes patients in need

of close monitoring are given home-based telehealth equipment to record and forward

daily glucose readings and other vital statistics to nurses in local health departments and

community health centers.

The Delta Health Partnership provides comprehensive diabetes care for an underserved

population of predominantly African American patients in rural areas of the Mississippi

Delta region. Funded by the federal Office for the Advancement of Telehealth, the

project uses videoconferencing to link local nurse practitioners, physician assistants, and

pharmacists with a multidisciplinary diabetes team for patient consultations, patient

and provider education, case management, and quality assurance.

Between July 2003 and December 2007, the Veterans Health Administration (VHA)

introduced a national home telehealth program to coordinate the care of patients with


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chronic conditions and avoid their unnecessary admission to long-term institutional

care.

Essentia Health of Minnesota is using telehealth to home monitor and prevent the

hospitalization of patients with heart problems as part of accountable care organization

(ACO) created under the Affordable Care Act.

Home-based primary care of the elderly to avoid institutionalization

A new school of thought is emerging relative to health care for the elderly, particularly those

with multiple chronic conditions that can result in very costly institutional care that prolongs

their lives but does not improve quality of life. A new approach keeps these patients in their

homes through the provision of intensive, coordinated primary care. Given an expected

increase in those suffering from Alzheimer’s and other forms of dementia as the baby boomer

demographic ages, telehealth home monitoring of these patients could prove beneficial and

help mitigate institutionalization. A 2007 study found televideo monitoring could improve

medication self-administration accuracy and improve mood for persons with mild dementia

who live alone or spend a significant amount of their day alone.

Mental health care

According to a recent estimate, psychologists, psychiatrists, and clinical social workers

accounted for 49 percent of the health care professionals who provided 10 or more telehealth

services in Medicare.

David Pruitt, M.D., director of the Division of Child and Adolescent Psychiatry at the University

of Maryland, notes shortage of pediatric specialists will deepen with the Affordable Care Act,

which is expected to bring in large numbers of new Medicaid recipients, 40 percent of whom

will be children.

In an institutional application, veterans returning from deployments to the Middle East are

being provided mental health care via telehealth through the Veterans Administration.

Quality of Care and patient safety

There exist few studies on the quality of care and patient safety for patients who received

telehealth services provided by licensed health care professionals. Those that were identified

are positive, including one finding quality of care was rated higher by physicians and patients.

Another found telehealth could result in fewer medication errors in rural emergency

departments.

http://www.kaiserhealthnews.org/Stories/2011/January/13/ACO-accountable-care-organization-FAQ.aspx


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Some practitioners however note telehealth remains relatively new and warrants prudence.

Concerns are raised in terms of making accurate diagnoses remotely for conditions that require

testing and follow up care. Other practitioners emphasize the need for a primary care physician

relationship, noting that a telehealth consult with a physician where there is no pre-existing

provider-patient relationship cannot wholly replace the need for a primary care medical home.

Researchers caution that more research is necessary to further assess the quality and safety of

primary care delivered by telehealth services. There are concerns that its expanded use may

lead to fragmentation of care since physicians do not have access to information (due to the

lack of integration of EHRs) that can be gathered during a patient exam or diagnostic testing.

Some providers fear these and other limitations can lead to misdiagnosis and higher rates of

follow-up visits. A 2010 study suggests remote care of primary care patients is more

appropriate for follow up care than initial visits.

Some practitioners have different methods for how they assess patients remotely versus co-

located with the patient in person. Some believe practitioners must be able to spot red flags

that signal the need for referral to an ER or urgent care center. “There are some things where

someone needs to lay eyes on you,” one physician observes. Many practitioners see the benefit

of using telehealth to treat patients in rural areas, but nevertheless see limitations. While

ailments like poison ivy and minor colds are treatable using only telehealth, some practitioners

believe many diagnoses must be made with a face-to-face, co-located office visit.

Some observers foresee a broader risk associated with the growing use of health telematics

that does not involve providers laying hands on patients. They point to an increasing reliance

upon technology and the “de-skilling” this may entail for medical professionals that some

similarly believe airline pilots operating modern aircraft with automated controls can

experience relative to hands on piloting skills.

Standard of care for telehealth

As telehealth more closely approximates the traditional, co-located provider-patient encounter

with the introduction of real time videoconferencing, questions arise as to what standard of

care should govern. For example, should the same standard of care apply uniformly regardless

of whether the patient encounter occurs in a co-located setting or remotely via telehealth? Or

should new and additional standards be developed for the new, online-enabled generation of

telehealth?

Some maintain existing clinical risk management and patient safety processes within legacy

healthcare platforms offer the structure, process and outcomes that are necessary to ensure

telehealth programs are implemented and sustained in a safe, appropriate and effective way.


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Others believe that in order to ensure telehealth services maintain current levels of patient

safety, underlying clinical, technology and business processes should be standardized as part of

a systems approach to healthcare transformation.

These concerns were highlighted by the authors of a study of a large California agency serving

public employees who engaged in remote telehealth visits with primary care providers. The

findings, published in early 2014 in the journal Health Affairs, represent the first assessment of

a telemedicine program offered to a large, diverse group of patients across the United States.

“Although telehealth is, in many respects, a fundamentally different model for providing health

care, very few standards have been developed to guide practitioners on how to safely and

effectively administer telehealth services,” the authors opine. “This includes, for example,

standards and protocols to prevent transmission errors that could cut off remote

communications, standards on how to properly use telehealth equipment (such as imaging

devices), and standards relating to the informed consent process in the telehealth setting.” The

authors assert it is “imperative that hospitals and health systems develop protocols and

standards around their telehealth practice, and supply patients with information upfront that

highlights the medical risks associated with telehealth.” Moreover, they write despite the

potential benefits of telehealth applications, little is known about their overall impact on care.

The study authors found providers saw patients with many diagnoses that typically require a

physical exam, diagnostic testing, or both. They additionally found patients using the primary

care telehealth provider Teladoc were less likely to have a follow-up visit to any setting,

compared to those patients who physically visited a physician’s office or emergency

department.

One academic paper acknowledges the significant potential benefits of home monitoring

telehealth services for patients with multiple chronic conditions including decreased rates of

mortality, improved quality of life and savings for third party payers. But the current regulatory

process does not provide adequate oversight and standards for these systems that transmit and

process data (telehealth systems) critical for patient management, the paper’s authors argue.

Home telehealth vendors must address the possibility that increased utilization increases their

risk of liability due to patient safety issues including effectiveness of patient management,

evidence-based outcomes, regulation, cost effectiveness and reimbursement and certification

to ensure reliability.


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Sections 2 and 3: Federal and state law and regulations governing the

administration of telehealth services delivered by licensed health care

professionals

Federal and state statutes and regulations pertaining to telehealth services by licensed healing

arts practitioners were compiled and reviewed. The scope generally excluded telehealth-

related authorities pertaining to health care facilities, state medical assistance programs, state

telehealth initiatives, and public and private health insurance. In addition, a Lexis/Nexis search

of federal court decisions was conducted to identify federal common law mandates on states

pertaining delivery of telehealth services.

The federal government defines and regulates the delivery of telehealth services in these

contexts:

1. Medicare and Medicaid and practitioner reimbursement;

2. Home and community-based services for elderly and disabled individuals;

3. Food and Drug Administration law relative to online pharmacy; and

4. Federal health care programs including the Public Health Service, Indian Health Service,

and the Veterans Health Administration.

These federal programs employ differing definitions of telehealth or telemedicine. Relative to

Medicare, federal statute (the Social Security Act) defines “telehealth service” as “professional

consultations, office visits, and office psychiatry services…and any additional service specified

by the Secretary.” The Social Security Act also defines telehealth services using location-based

parameters including “originating site” (where the patient is located when receiving services)

and “distant site” (the location of the practitioner while patient services are being delivered) as

well as the scope of practitioners who may provide telehealth services.

Medicare rules define “telehealth services” as encompassing an interactive telecommunications

system using multimedia communications equipment that includes, at a minimum, audio and

video equipment permitting two-way, real-time interactive communication between the

patient and distant site physician or practitioner. The definition also includes the “store and

forward” transfer of patient information to another provider for confirming a diagnosis and/or

treatment plan.

Medicaid program guidance states “telemedicine seeks to improve a patient's health by

permitting two-way, real time interactive communication between the patient, and the

physician or practitioner at the distant site. This electronic communication means the use of

interactive telecommunications equipment that includes, at a minimum, audio and video

equipment.” The web site also defines “telehealth and telemonitoring” as “the use of


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telecommunications and information technology to provide access to health assessment,

diagnosis, intervention, consultation, supervision and information across distance.”

Regulations promulgated by the Drug Enforcement Administration (DEA) define the “practice of

telemedicine” as "practice of medicine in accordance with applicable Federal and State laws by

a practitioner (other than a pharmacist) who is at a location remote from the patient and is

communicating with the patient, or health care professional who is treating the patient, using a

telecommunications system...”

In the context of federal health care centers, federal statute specifically recognizes the

definition of telehealth as including mental health service and broadly defines it as “the use of

electronic information and telecommunications technologies to support long distance clinical

health care, patient and professional health-related education, public health, and health

administration.”

For the purposes of Medicare, the law contemplates telehealth services as serving areas where

there are fewer available practitioners, limiting their delivery to rural Health Professional

Shortage Areas, either located outside of a Metropolitan Statistical Area (MSA) or in a rural

census tract or counties outside of a MSA. Notably, the statute specifies originating sites can

only be physician offices and specified health care facilities.

Federal law defines the types of practitioners who may be reimbursed under Medicare for

telehealth services are listed in two categories. The first is physicians, broadly defined as:

Physicians and osteopaths

Dentists

Podiatrists

Optometrists

Chiropractors

The second category is defined in statute as “practitioner” and includes:

Physician assistants, nurse practitioners, or clinical nurse specialists

Certified registered nurse anesthetists

Certified nurse-midwives

Clinical social workers

Clinical psychologists

Registered dietitians or nutrition professionals


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Notably, professionals are required to be licensed in the state in which they perform functions

within the scope of their licensure. Medicare regulations specifically require the physician or

practitioner at the distant site be licensed to furnish the service under state law.

Wide variation among states

There is a wide variation among state statutes and regulations governing the delivery of

telehealth services by healing arts licensees. Some states have relatively extensive bodies of law

including five states (New Hampshire, New Mexico, Nebraska, Oklahoma and California) that

have enacted omnibus telemedicine or telehealth statutes, while other states have been

minimally active in this area.

Several states have not enacted any statutes or promulgated regulations pertaining to the

delivery of services via telehealth by licensed health care practitioners. Nearly all states

regulate telehealth practice by physicians and osteopathic physicians, although a small number

do not (such as Ohio and South Dakota) where telehealth laws solely govern other licensed

healing arts. Many states specifically regulate telehealth practiced by licensees including nurses,

physician assistants, mental health providers, audiologists and speech pathologists, physical

therapists, optometrists and dentists.

States vary in how they define telehealth (some use the term “telemedicine”). Several (Alaska,

Arizona, Louisiana, Oklahoma) define it as a practice of health care delivery when provider and

patient are not physically co-located using information and communications technology.

California has adopted a relatively broad definition, defining telehealth as “the mode of

delivering health care services and public health via information and communication

technologies to facilitate the diagnosis, consultation, treatment, education, care management,

and self-management of a patient's health care.” One state (Montana) defines telehealth as

practiced exclusively by out of state practitioners for patients within the state, while others

limit its use to in-state licensed practitioners.

Consistent with model policy issued by the Federation of State Medical Boards (FSMB) as this

review was being completed, nearly half of all states define telehealth in the context of a live

interaction between patient and provider.

Two states (South Dakota, Vermont) limit the definition of telehealth to the monitoring of

patients in their homes. One state (Maryland) regulates telehealth provided by physicians by

establishing rules that specifically apply to physicians using websites for the delivery of

telehealth. Most states exclude telephone, facsimile and electronic mail communications from

the definition of telehealth other than to augment telehealth care.


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While most states with telehealth laws include a form of telehealth known as “store and

forward” (use of information and communications technology to transmit data, images, sounds

or video from one care site to another for evaluation) in the definition of telehealth, some

exclude it. California includes both synchronous patient-provider interactions and asynchronous

store and forward transfers in its definition of telehealth.

Only one state, West Virginia, has law specific to the practice of pharmacy in the context of

telehealth. The law defines the practice of “telepharmacy" as the provision of pharmacist care

by properly licensed pharmacists located within the United States through the use of

telecommunications or other technologies. A face-to-face physical examination adequate to

establish the medical complaint must be performed by the prescribing practitioner.

Standards of practice in state law

A handful of states have codified relatively extensive standards of practice regulating the use of

telehealth by licensed health care professionals including Florida, Kentucky, Louisiana,

Maryland and Texas. These as well as other states have adopted threshold requirements

providers must meet in order to establish a telehealth provider-patient relationship before care

is provided including:

Informed consent to receiving care by telehealth;

Verification of patient’s identity;

Written patient notification of provider’s privacy practices;

An initial patient examination;

Disclosure to patient of risks, consequences and benefits of telehealth, right to

withdraw consent, how to receive follow-up care or assistance in the event of an

adverse reaction to treatment or if there is a telemedicine equipment failure

Notice of how to file a complaint against the provider;

Access to pertinent portions of the patient's medical record and;

Support staff trained to conduct telehealth patient visit, implement physician orders,

identify where medical records generated by the visit are to be transmitted for future

access, and provide or arrange back up, follow up, and emergency care to the patient.

In most states, there are ongoing provider requirements to ensure patient safety that govern

the delivery of care via telehealth including:

Protocols to prevent fraud and abuse through the use of telehealth medical services;

Adequate security measures to ensure that all patient communications, recordings and

records remain confidential;


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Procedures to prevent access to data by unauthorized persons through password

protection, encryption, or other means;

Policies on how quickly patients can expect a response from the physician to questions

or other requests included in transmissions and;

Maintenance of a complete record of the patient's care.

Notably, only some of these standards appear in the April 2014 FSMB model policy: verification

of the patient’s identity, informed consent and security of patient data.

Louisiana delineates the elements that define establishment of a physician-patient telehealth

relationship including evaluation (review of any relevant history, laboratory or diagnostic

studies, diagnoses, or other information deemed pertinent by the physician); diagnosis of the

patient's disorder, illness, disease or condition and the reason for which treatment is being

sought or provided; treatment plan and a plan for follow-up care provided to the patient in

writing and documented in the patient's record.

For patients seen at other than an established medical site, Texas requires physicians to

conduct initial patient visits at the same location with the patient except when the patient has

received an in-person evaluation by another physician who has referred the patient and the

referral is documented in the medical record. Texas also requires a co-located physician-patient

visit be conducted at least annually in the context of providing care via telehealth.

Texas employs an information-based parity standard relative to medical practice. Physicians

must be able to obtain all pertinent clinical information in the context of a telehealth encounter

that a health care provider exercising ordinary skill and care would deem reasonably necessary

for the practice of medicine at an acceptable level of safety and quality. If all the necessary

information cannot be obtained in the context of a telehealth encounter, Texas law requires

physicians to advise patients prior to the conclusion of the telehealth encounter of the need for

additional in-person evaluation.

As with the FSMB model policy, Maryland law recognizes the establishment of a physician-

patient relationship without an initial, co-located face-to-face interaction provided physicians

incorporate “real-time auditory communications or real-time visual and auditory

communications to allow a free exchange of information between the patient and the physician

performing the patient evaluation.”

Several states (Colorado, Florida, Hawaii, and North Carolina) incorporate a parity standard into

their laws and regulations governing telehealth, explicitly stating standards of practice and

professional misconduct apply equally to care provided patients via telehealth and in settings


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where patient and provider are co-located. Colorado statute specifically includes telemedicine

within the definition of practice of medicine. One state (Wisconsin) requires telehealth be

“functionally equivalent to face to face contact.”

Telehealth and practice across state lines

Most states prohibit practitioners licensed in other states from delivering services via telehealth

to patients residing within their jurisdictions. In about half the states, however, the law is silent

on delivery of telehealth services by health care professionals licensed in other states.

In the context of telehealth, several states exempt from physician licensure requirements

consultations between physicians, typically relative to “store and forward” telehealth

consultations among practitioners, where patient diagnostic information such as imagery is

transmitted to an out of state physician for review and medical opinion. Oregon law allows

telehealth monitoring by physicians licensed in other states in a single circumstance: to monitor

surgical patients. Under this provision, Oregon health care facilities must grant privileges to

these physicians and request the state medical board grant them active telemonitoring status.

Apparently in recognition of interstate telehealth practice by physicians, nine states issue

specialized telehealth licenses or certificates that permit a practitioner licensed in another state

to practice within their jurisdictions under certain conditions. States authorizing special

telehealth licensure for physicians licensed in other states include:

Alabama

Louisiana

Montana

New Mexico

Nevada

Ohio

Oklahoma

Tennessee

Texas

Minnesota allows physicians licensed in other states to practice telemedicine with patients

located in Minnesota if they register with the medical board and refrain from opening an office

in the state or meeting with or receiving calls from patients while both provider and patient are

in Minnesota.

Hawaii allows physicians licensed in other states to practice telehealth on Hawaii residents if

they have a pre-existing provider-patient relationship. However, Hawaii law prohibits the use of


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telehealth to establish a physician-patient relationship with a resident of Hawaii without a

Hawaii license.

Some states allow out of state physicians to practice within their jurisdictions if they hold

licensure in adjoining states or by reciprocal licensing with other states. States allowing practice

under specified conditions by physicians licensed in bordering states include Texas,

Pennsylvania, Maryland and Washington. Only three states (Alabama, North Dakota and South

Dakota) have reciprocal licensure laws. These border state practice and reciprocal licensure

laws effectively permit the limited interstate practice of telehealth within their jurisdictions.


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Section 4: National stakeholder group positions

In this report section, the public policy positions of national stakeholder groups with an interest

in telehealth services were researched. Stakeholder organizations with detailed policy positions

relative to the delivery of health care services via telehealth include the American Medical

Association (AMA), the American Telemedicine Association (ATA) and the Alliance for

Connected Care.

Timely to the Utah Telehealth Study was the release of model policy governing the use of

telehealth in medical practice by the Federation of State Medical Boards (FSMB) in April 2014.

This policy seeks to blend traditional practice -- where physicians develop a face-to-face doctor-

patient relationship -- with advances in information and communications technology that

enable visual interaction using secure videoconferencing.

A key component of the FSMB model policy is a standard of care parity principle. In the context

of a telehealth physician-patient relationship, physicians must be able to obtain sufficient

patient information in order to develop a diagnosis and treatment plan in order to meet the

standard of care that would apply to patients seen in a traditional co-located physician office

setting. This parity principle mirrors Texas law as well as the World Medical Association’s

(WMA) Standards of Practice/Quality of Clinical Care guidelines for physicians who use

telehealth to provide health care services.

The stated policy intent of the FSMB model policy is “to offer a model policy for use by state

medical boards in order to remove regulatory barriers to widespread appropriate adoption of

telemedicine technologies for delivering care while ensuring the public health and safety.” It

defines telemedicine as:

[T]he practice of medicine using electronic communications, information technology or other

means between a licensee in one location, and a patient in another location with or without an

intervening healthcare provider. Generally, telemedicine is not an audio-only, telephone

conversation, e-mail/instant messaging conversation, or fax. It typically involves the application

of secure videoconferencing or store and forward technology to provide or support healthcare

delivery by replicating the interaction of a traditional, encounter in person between a provider

and a patient.

The FSMB model policy also defines “telemedicine technologies” that enable telemedicine and

recognizes the need for secure communications between physicians and patients, consistent

with provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPPA)

regulating the use and disclosure of Protected Health Information (PHI) held by "covered

entities" including medical service providers:

http://en.wikipedia.org/wiki/Protected_health_information


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“Telemedicine Technologies” means technologies and devices enabling secure electronic

communications and information exchange between a licensee in one location and a patient in

another location with or without an intervening healthcare provider.

Notably, the FSMB model policy does allow a new physician-patient relationship be established

without an initial co-located, in person visit through the use of telemedicine technologies with

the proviso the standard of care and other conditions are met.

Some practitioner groups have developed model law incorporating telehealth including the

National Council of State Boards of Nursing (NCSBN), the National Association of Boards of

Pharmacy (NABP) and the Association of Social Work Boards (ASWB). The NCSBN supports

state-based licensure but has adopted an interstate compact approach to facilitate the

provision of care by telehealth across state lines.

The ASWB model act incorporates a license by endorsement principle, provided requirements

for licensure in the jurisdiction of licensure are substantially similar to the requirements for

licensure in the temporary practice jurisdiction. Interestingly, the ASWB model act devotes a

section to “telepractice” but does not define it per se and instead recommends states instead

address it as a temporary privileging for practitioners not licensed in their jurisdictions:

Rather than attempting to define “telepractice” or create a limited license to address out-of-

state practitioners, it is recommended that legislatures address these technologically driven

practice issues through a temporary practice approach. This temporary practice language is

intended to address sporadic practice within the jurisdiction irrespective of whether it is

electronically rendered or rendered in person. The privilege of practicing temporarily (no more

than 30 days per year) is only granted to individuals duly licensed to practice social work in

another jurisdiction.

Other professional organizations have opted for a model compact (the Federation of State

Boards of Physical Therapy), and interstate licensure reciprocity (the Association of State and

Provincial Psychology Boards).

In some respects, the issue of regulation of telehealth services delivered by licensed health care

professionals and the appropriate standard of care has been framed as a larger policy issue:

whether states should retain plenary regulatory authority over health care professionals who

practice telehealth. The American Telemedicine Association (ATA) views state licensure as an

obstacle to telehealth practice, a view shared by a recently formed advocacy organization, the

Alliance for Connected Care. The Alliance calls for the elimination of state regulatory and

licensure barriers to the practice of telehealth that prohibit providers from furnishing telehealth


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services to patients across state lines as well as the establishment of a multi-stakeholder

process to develop a standard definition of safe, high quality telehealth services and connected

care.

Another organization, the Information Technology and Innovation Foundation (ITIF), urges

Congress to create a federal standard for telehealth that states should adopt. If states fail to do

so, Congress should adopt a uniform national license for telehealth that would be required to

be accepted in all states.

However provider groups – most notably the AMA – as well as the NCSBN, NABP and ASWB and

the American Pharmacists Association (APhA) -- have adopted policy positions respecting state

licensure authority over health care professionals, with flexibility to accommodate delivery of

telehealth services by practitioners licensed in other states. For example, the AMA supports a

special telemedicine license category covering compensated services where a medical opinion

by a physician licensed in another jurisdiction is used in patient diagnosis or treatment.

The NABP Model Act incorporates the “practice of telepharmacy across state lines.” Like the

FSMB model policy, the NABP Model Act places substantial emphasis on the establishment of a

patient-practitioner relationship that meets specified conditions that ensure prescribing occurs

in a medical context and that a health care practitioner ensures a bona fide patient medical

complaint exists.

Association of State and Provincial Psychology Boards (ASPPB) has developed an the ASPPB

Agreement of Reciprocity (AOR) that encourages states and provinces to enter into a

cooperative agreement whereby any individual holding a license in one AOR participating

jurisdiction may obtain a license to practice in another AOR participating jurisdiction.

According to the ASPPB, the following jurisdictions are party to the AOR:

Arkansas Manitoba Missouri Nebraska Oklahoma Ontario Texas


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Research conducted during this phase of the project found 10 practitioner organizations that

have no public policy positions on telehealth:

American College of Nurse Midwives (ACNM)

American Association of Nurse Practitioners (AANP)

American Nurses Association (ANA)

American Association of Marriage and Family Therapy (AAMFT)

Association of Marriage and Family Therapy Boards (AMFTRB)

American Psychological Association (APA)

American Mental Health Counselors Association (AMHCA)

National Board of Certified Counselors (NBCC)

National Association of Alcohol and Drug Abuse Counselors (NAADAC)

National Association of Social Workers (NASW)

Policy questions presented/topics for further study

1. To what extent do patients require care by health care professionals licensed outside

patients’ state of residence in terms of type, amount and frequency?

2. To what extent does state licensure create obstacles to the delivery of care via

telehealth by health care professionals to patients outside their states of licensure?

3. Are these obstacles having a significant adverse impact on patients’ ability of to obtain

needed care?

4. Does existing law provide sufficient leeway for health care professionals to provide

services to patients located outside their jurisdiction of licensure?

5. Is telecommunications infrastructure sufficiently developed to enable nationwide

application of the FSMB model policy guidance that defines telemedicine as “typically

involv[ing] the application of secure videoconferencing…” If not, when will it reach that

point?

6. As an alternative or interim mode of flexibility to accommodate the interstate practice

of telehealth by licensed health care professionals as policy and technological

developments play out, should states consider 30-day “temporary privileging” for

practitioners licensed in other states as proposed in the ASWB model act?

Utah Telehealth Study – Summary Report Prepared by …utah.gov/pmn/files/109907.pdf · follows that adopted by the World Medical ... is expanding into ... Utah Telehealth Study

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